1. 5 th Sexual Dysfunction Conference Queenstown NZ April 2012 Ejaculation Disorders Too Fast and Too Slow Dr Michael Lowy Sexual Health Physician Sydney Men’s Health Bondi Junction, Sydney mlowy@sydneymenshealth.com.au Sydney Men’s Health

2. Ejaculation COMPONENTS Emission Ejaculation Orgasm TYPES Rapid/premature Delayed/inhibited Retrograde Sydney Men’s Health

3. Limbic System

4. Sydney Men’s Health5

5. Stages of normal ejaculatory physiology Emission (sympathetic T10-L2) – Bladder neck closure – Deposition of seminal fluid into posterior urethra Ejection (parasympathetic S2-S4) – Expulsion of seminal fluid from the urethra – Relaxation of the external sphincter – Co-ordinated pelvic floor, bulbospongiosis contraction Orgasm – A sensory experience via pudendal nerve associated with all these events Sydney Men’s Health

6. Hyposensitivity of MPO of hypothalamus – 5-HT2C Hypersensitivity of MPO area of hypothalamus – 5-HT1A

7. Arousal Pudendal nerves Spinothalamic tract Thalamus/limbic system Hypothalamus: MPOA, D1 & D2 Reticulospinal tracts Sympathetic T10-L1 Parasympathetic S2,3,4 Ejaculation Sydney Men’s Health

9. PE

10. Sydney Men’s Health

12. Definition PE Lack of control of ejaculation Dissatisfaction of sexual experience Distress to man and his partner Latency times (IELT) Often associated with a secondary performance anxiety Erectile dysfunction is often secondary to long term PE Sydney Men’s Health

13. ISSM definition of PE Ejaculation which always or nearly always occurs prior to or within about 1 minute of vaginal penetration Inability to delay ejaculation on all or nearly all vaginal penetrations Negative personal consequences, such as distress, bother, frustration &/or the avoidance of sexual intimacy Sydney Men’s Health

15. Normal ejaculation time Faster ejaculation Sydney Men’s Health

17. Ejaculatory Dysfunction 30% of men say they have a problem controlling ejaculation 90% of ejaculation problems are PE 5-10% of men complain of severe PE Prevalence PE 8-31%, delayed 2-4% Sydney Men’s Health

19. Intra-vaginal ejaculation latency time (IELT) PE level of distress depends if mild or severe IELT median time 5.4 minutes (range 1-45 min) IELT < 1 minute – definite PE IELT 1-1.5 minutes – probable PE Lifelong PE – 1.5 minutes 90% of intercourse Acquired PE – developed IELT < 1.5 minutes Sydney Men’s Health

22. Taxonomy of PE JSM 2011;8(suppl 4):328-334 Onset – 1 ° lifelong (from the first sexual experience) –2° acquired (after a period of normal ejaculation) Time – Before vaginal penetration – During vaginal penetration Type – In all situations – In specific situations Co-morbidities – No other sexual symptoms – Presence of other symptoms e.g ED Sydney Men’s Health

23. PE SYNDROME Marcel Waldinger Primary or lifelong (younger men) – medication Secondary or acquired (older men) – medication, counselling Natural Variable PE – counselling PE like ejaculation syndrome – counselling Sydney Men’s Health

27. Premature Ejaculation Diagnostic Tool Sydney Men’s Health

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31. Treatment of Premature Ejaculation Incorporate into sexual practice: "go with the flow" - work on intimacy Sexual script change: extend foreplay, modify rigid sex patterns, “partner first” Improve IELT, address relationship issues, restore confidence Sydney Men’s Health

32. Treatment PE cont’d Behavioural techniques - stop/start (Seman), squeeze (Masters & Johnson) Oral medication - SSRI, clomipramine, PDE5i Intra-cavernosal injections Anaesthetic spray (Stud Spray) Pelvic floor exercises Surgery to dorsal nerve (Brazil) Sydney Men’s Health

33. PE issues Interview partner – Obtain more accurate IELT – Check issues of FSD Alcohol use delays ejaculation Acquired 2°PE factors – hyperthyroidism, prostatitis, ED Assessment: history, stopwatch IELT, examination (optional, not mandatory, reassuring) PE returns when medication is stopped Sydney Men’s Health

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36. Counselling for PE Rowland D. JSM 2011;8(suppl 4):342-352 Address physiological, psycho-behavioural, cultural & relationship factors As PE is a couples problem, counselling best with partner present Initial medical history: sexual, psychological, relationship Psychotherapy domains: behavioural, cognitive, affective, relational Pharmacotherapy can augment psychotherapy Sydney Men’s Health

37. J Sex Med 2012;9:576–584

38. Women with men who have PE Women’s Sexual Function & Dysfunction Sydney Men’s Health39

39. Sydney Men’s Health

41. Stop/Start Technique Sydney Men’s Health

45. Dapoxetine - Priligy T max 1.2 hours T ½ 18 hours IELT 30mg 3.48x IELT 60mg 3.68x Side effects: nausea, headache

46. Sydney Men’s Health

50. Evidence-based research into both the methodology, content, duration and intensity as well as the short and long term results of psychological treatment of PE is encouraged Level 3 evidence to suggest that all men seeking treatment for PE should receive basic psychosexual education Graded levels of patient and couple counselling, guidance and/or relationship therapy, either alone or ideally in combination with PE pharmacotherapy should be offered as a treatment option for most men with PE

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52. Delayed Ejaculation Often a normal part of ageing Younger men - angry, withholding Relationship issues – conception Consider idiosyncratic masturbatory style (traumatic masturbatory syndrome) – conditioned inhibition TREAT (enhance arousal) Pre & post masturbation/vibration Scrotal/perineal tickling Incorporate into normal practice Sydney Men’s Health

56. Retrograde Ejaculation Common after benign prostate or bladder neck surgery Some disease conditions – diabetes, neurological Agonist medications may help e.g. Sudafed, Periactin, Symmetrel Sydney Men’s Health

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